Michelle Sitrick
The PLISSIT Model of Sex Therapy
The PLISSIT Model
The PLISSIT Model of sex therapy, developed by psychologist Jack Annon, is based on the idea that the majority of people can resolve their sexual related problems by following a basic four-step program. “PLISSIT” is an acronym for the four levels of intervention, which include Permission (P), Limited Information (LI), Specific Suggestions (SS), and Intensive Therapy (IT). The model follows a vertical structure, requiring greater knowledge and training as one moves up each level (Taylor & Davis, 2007). The first thr
PLISSIT.jpg
A visual hierarchy of the various levels of the PLISSIT Model, showing the separation between brief and intensive therapy.
ee levels are generally classified as brief therapy, whereas the last step is seen as intensive therapy (Madorsky & Dixon, 1983). In this way, the model helps to first identify cases that can be treated most simply, simultaneously separating those rare cases that require a more complex therapy plan or referral to other outside sources (Haeberle, 2003). Additionally, the model can be utilized with many different cultural groups, as it is flexible and adaptive, and does not require translation into other languages. This is because there is not one set script of questions, but rather the therapist adapts his dialogue to fit each individual case. (Wallace, M.A. 2008). Furthermore, it is also applicable to homosexual patients or those with concerns on gender identity. Overall, the program provides the client with both education as well as behavioral strategies, in order to eliminate sexual problems for many people without a long, intensive course of therapy.

Permission
The first step of the model, Permission, essentially serves to give clients permission to speak about their sexual concerns. It also helps to validate the issue as a legitimate health concern, helping the clients to acknowledge that their feelings are justified and deserve attention (Ohl, 2007). It is based on the notion that many sexual problems result from a variety of negative emotions, such as anxiety or guilt. Additionally, clients might be experiencing feelings of inhibition towards sex, such as embarrassment and self-consciousness (Haeberle, 2003). Therefore, the therapist can often alleviate the client’s discomfort by providing permission to continue to do what he is already doing in regard to sex. For example, a client experiencing guilt for engaging in masturbation may be given permission to do so, eliminating the negative feelings he had as a result. The therapist should also develop an environment of openness and comfort during this stage (Ohl, 2007). This will help ensure that the client will feel able to be honest with his partner and the therapist.
Limited Information
The next step of the model, Limited Information, is rather straight- forward, with an informative, educational approach. For example, during this step the client may be given anatomical and physiological information about how he and his partner’s bodies work and what is considered normal during sex (Haeberle, 2003). This helps to eliminate any false or unrealistic expectations the client may have, which also helps to reduce feelings of anxiety or frustration. Additionally, for clients who have various physical disabilities, this step may include education on different adaptations that can be made during sex to reduce problems related to mobility or other physiological symptoms (Madorsky & Dixon, 1983). Patients may also be given additional materials such as books, magazines, videos, etc. to provide relevant and accurate information.
Specific Suggestions
The third stage provides specific tips, directions, and exercises used to treat sexual problems; tailored to meet the specific needs of each individual case (Haeberle, 2003). In order to determine these specific suggestions, a sexual history of the client and his partner is obtained to collect information on various health issues, as well as personal strengths and information about the relationship (Madorsky & Dixon, 1983). Additional goals during this stage include expanding attitudes on sexuality in general, reducing feelings of performance anxiety, and increasing effective communication skills between partners. The therapist will then provide specific directions for the client to follow. This may include self- stimulation, drawing attention to sexual sensations and impulses, taking note of negative thoughts and analyzing their meaning, using various sensual materials such as music or candles to enhance the sexual experience, employing stimulating devices or sex toys, and engaging in fantasies (Ohl, 2007). In turn, these exercises have been shown to provide much improvement on a variety of sexual issues.
Intensive Therapy
In the last step of the model, Intensive Therapy, the therapist determines which cases are resulting from additional underlying causes, as well as which patients may need additional referrals to medical professionals. This includes individuals who meet guidelines for having a sexual dysfunction disorder, or who are experiencing problems occurring during one or more of the sexual response cycles, which include desire, excitement, orgasm, and resolution (Wallace, 2008). This might also include patients who are dealing with any physical or emotional disabilities, as well as patients who suffer from a psychiatric disorder such as depression, obsessive-compulsive disorder, personality disorder, or substance abuse (Ohl, 2007). In order to obtain this information, it is necessary that the therapist conduct a comprehensive interview during the first meeting. The interview should include questions regarding the patient’s childhood and upbringing, including the relationships he had with friends and family members. This is an important way to gather data on the client’s current relationships and overall self-esteem. It is also necessary to determine whether there was a history of sexual abuse or trauma. Religious beliefs should also be discussed, as these often directly tie to an individual’s beliefs toward sexuality, such as how one feels about sex before marriage. The final step in the interview is to gather the client’s medical history, such as medications they are taking, any physical limitations they may have, and a general understanding of the individual’s overall health.
Once a complete evaluation has been obtained, the therapist will provide an explanation as to what factors might be contributing to the problem, as well as prescribe a specific treatment plan. This treatment plan generally requires the cooperation and participation of the partner, as well as the client. There is a strong emphasis on expression of feelings during this stage, as the couple should disclose how they feel about past and present occurrences (Ohl, 2007). The overall goal is to identify and eliminate any maladaptive behaviors, ultimately strengthening interpersonal communication and helping to discover and implement new ways to deal with sexual issues. One way this is accomplished is through the assigning of homework in order to practice the skills discussed in therapy. Examples of homework might include learning the most effective ways to give and receive pleasure, eliminating anxiety and fears while focusing on pleasure, and converting the concept of sexual obligation into pleasure (Ohl, 2007). Furthermore, there is a strong focus on communication skills, so that the client learns successful ways to express his sexual needs and desires, which should also eliminate harmful patterns and reduce frustrations in regard to the sexual relationship. This might even include requesting that the couples refrain from penetration or touching sexual organs for a specified period of time, or purposely prevent reaching orgasm, in order to practice other sexual acts. Overall, the PLISSIT model provides a comprehensive plan to treat a variety of sexual problems without needing to resort to intensive psychotherapy.
References

Haeberle, E.J. (2003). Sexual dysfunctions and their treatment. Retrieved from http://www2.hu-berlin.de/sexology/ECE5/index.htm

Madorsky, J. G. B. & Dixon, T. P. (1983). Rehabilitation aspects of human sexuality. The Western Journal of Medicine, 139, 174-176.

Ohl, L.E. (2007). Essentials of female sexual dysfunction from a sex therapy perspective: The P-LI-SS-IT model for sexual counseling. Retrieved from http://www.medscape.com/viewarticle/555706_12

Taylor, B. & Davis, S. (2007). The extended PLISSIT model for addressing the sexual wellbeing of individuals with an acquired disability or chronic illness. Sexual Disability, 25, 135-139.
Wallace, M. A. (2008). Assessment of sexual health in older adults. American Journal of Nursing, 108 (7), 52-60.